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How to deal with unethical/billing issues at work?

  1. Default How to deal with unethical/billing issues at work?
    Medical Coding Books
    Has anyone dealt with unethical billing issues at work with respect to coding -being told not to list the documented and most obvious codes but rather "find" "some other code" that can be used so insurance will pay? When I said that was not legal or ethical, I am getting double talk. I know in my heart that the office is heading down the wrong path but the manager doesn't agree. They have already started using different codes, and on claims that previously paid, they are now are getting denied and the provider has lost money. So, instead of the provider getting paid, the opposite is actually happening. The office is in a real mess right now because we have stacks of claims that we need "to find other codes" for. I am concerned about the providers being audited and the effect an audit will have on the coders. If anyone has any ideas or can help, PLEASE write me. Thank you!

  2. #2
    Hi Grandma Coder,

    AAPC members agree to uphold a high standard of ethics. If you are being instructed to code incorrectly in order to get claims paid -- that is fraud! You could be putting your certification in jeopardy if you go along with this. You need to protect yourself. Put your concerns in writing and present them to your manager. Has your manager ever heard of whistleblowers? If the office gets audited, the OIG won't care that you needed a job and just kept on coding incorrectly.

    It's hard, especially in these tough economic times, but you have to be willing to walk away from the job if fraud is being committed.

    You know in your heart what is happening is wrong and it's wearing on your conscience. Do what's right -- don't compromise your ethics.

    Good luck,
    Last edited by k-jag; 01-26-2009 at 12:11 AM.

  3. #3
    I would suggest doing some research on the OIG website. They list criminal enforcement actions, you may need to go in the archives, but I bet you will find several similar scenarios that have already been prosecuted. Billing non-covered services in a way that will get them paid seems to be a common theme.

    I am guessing this is a small practice and you don't have a corporate compliance person. That would be the first place to start if the manager is the problem. Next, what about the provider? Are they aware of the risk they are at with the current practices?

    I agree you need to document everything. I unfortunately have personal experience with an unethical employer. I had to leave after exhausting all possible efforts to fix the problem. I wasn't willing to risk my credentials or chance being placed on the OIG exclusions list.

    Good luck

    Laura, CPC

  4. #4

    first of all, I am so sorry that your employers have put you in a difficult situation.

    Unfortunately, if you know personally that incorrect and potentially abusive or fraudulent coding is being done, and you do nothing, you may be considered liable as well if auditors visit you. I know it's hard sometimes to communicate with the employers, but I would highly recommend that you document what you are finding and present your supervisors with your findings to give them the chance to correct.

    For your own safety, I would highly recommend (although I know it's difficult) that you report them to the OIG if correction does not happen. You need to protect yourself and your future career, and unfortunately they've left you in the crossfire.

    Please know that we all understand and support you in your difficult time.

    Take care.

  5. #5
    Hi Grandmacoder

    Are the physicians aware of this or is it just the office staff? You need to protect yourself as well as the office as best you can. I agree with everyone that you should document your concerns and make them known to all in the practice. Remind them that Auditors might be in their area and if any questionable activity is found, they might go back years. I know the Doctors would not want that.
    You do have options and I think you should look into them in order to save your career.

    Take care

  6. #6
    Duluth, Minnesota
    I'm not sure I understand the issue.... are they pulling codes from "nowhere"? from signs/symptoms that ARE NOT in the notes, dictated or documented?... OR, are they simply coding "more" dx's?...more specific that may (or may not) help get the services covered? What's wrong with coding what is in the documentaion? That's how we code here... we code via documentation. So, if the provider writes something on the superbill that's fine and dandy, BUT if documentation doesn't support it, it doesn't get coded/billed out... that being said - same holds true visa/versa - if they don't write it on the superbill, yet it is documented in the note, I can (and do) code it out.
    so what am I missing here? your boss wants you to fraudulently code, make up dx's to get services covered? OR, your boss wants more research done to see if there are other more sufficient dx's that may (or may not) help with some specific charges?.
    I know especially for lab charges, covered dx's are needed. We always do our research to make sure that the dx's written are documented and if those are not covered dx's for specific labs we do more research to see IF something is mentioned and "codeable"... and code accordingly..
    in short - if they're telling you to make up codes - THAT'S doubt
    if they're asking you to do a bit more research to see if at all possible something else can be coded - what's wrong with that? I wouldn't take off the codes already coded, but I would be sure to link the codes to services to help in covereage.
    Last edited by dmaec; 01-26-2009 at 10:59 AM.
    Donna, CPC, CPC-H

  7. Default
    Thanks for your reply!! It is a little more complicated than that. There is a set series of codes that the director does not want the coders to use at all - not even as secondary Dx. This is because the insurance companies, as a norm do NOT pay for them, (some do though). However, all of the medical history and documentation points to using this set series of codes. We are trying to find anything remotely related in order to connect with the CPT code but we rarely find anything and I am at a standstill.

  8. Default Ethical issues in office
    Thank you to everyone who replied. I guess you are not telling me something I don't already know. I just needed confirmation from my fellow coders! Thanks for the reminder to document and how an audit would not only affect the providers, but the coders as well.

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